For the Primary Care Provider: When to Refer to a Pain Specialist

A recommendations statement from the American Academy of Pain Medicine

The American Academy of Pain Medicine’s (AAPM) Shared Interest Group in Primary Care provided a forum for pain specialists and primary care clinicians to gather and address clinical areas of concern for their patients. With the understanding that most chronic pain care takes place in conjunction with a patient’s primary care provider, the Primary Care SIG members have collaborated on the creation of a document meant to assist primary care providers in providing their patients the best of chronic pain care. A key aspect in providing that care is knowing when to refer to a pain specialist.

These recommendations are not intended to dissuade primary care practitioners who are not pain specialists from managing chronic non-cancer pain patients in the primary care setting. Rather, the intent is to further enable primary care providers to improve the effectiveness and safety of the care they offer to their patients living with chronic pain. Some key points are provided below.

  • Chronic pain like all chronic medical illness requires patient self-management. Cure is rare and complete pain relief is rarer. Patients do best when they adopt a new lifestyle not solely dictated by the pain. The provider does best by offering support and encouragement; not necessarily by more testing, more medication, more referrals, or more procedures.
  • When to refer will depend on the expertise of the primary care provider and the availability of the pain specialist.
  • All pain practitioners/clinics are not the same. The referral may vary from a referral to a pain specialist who utilizes a single modality to interdisciplinary rehabilitation models. It is important to know who is available for consultation, what the specialist offers, and what expectations both the patient and the provider bring to the referral.
  • It is important to foster communication and develop relationships between a primary care and a specialist. This encourages collaboration on what may be a challenging patient population. Collaboration includes sharing medical records, jointly determining treatment plans, care coordination, etc.
  • Chronic pain can be defined in a variety of ways. Most experts agree that pain longer than the expected time of healing is a useful definition. Referral for evaluation and treatment early is important to break the cycle of chronicity and to aid in de-conditioning.
  • Know your state regulations and guidelines which may require referral at certain milestones such as milligram limits. For example, the CDC guidelines recommend extra precaution when prescribing 50mg or more morphine equivalents a day and avoiding 90mg or more. Referral of
    patients hitting these thresholds may be advisable for expert guidance as these thresholds indicate greater risk AND may indicate a failure of opioids to achieve functional goals. The specialist can assist in expanding the self-care training and other portions of the treatment plan.
  • Chronic pain may not have a known, easily definable cause despite an extensive primary care work up (e.g., low back pain, fibromyalgia, chronic daily headaches, etc.). Referral to a pain specialist to confirm or establish the diagnosis and offer suggestions on management is advisable.
  • If a procedure is indicated (e.g., low back pain with radiculopathy) or surgery is indicated (progressive neurologic deficit, cauda equina syndrome, etc.), a referral should be considered.
  • Chronic pain often co-exists with anxiety, depression, bipolar disorder, PTSD, and other psychiatric conditions. A referral to behavioral health services to optimize the management of these conditions may facilitate management of chronic pain.
  • If the cause of the pain is known (or unknown), serious disease excluded, no curative treatment is readily available, current treatment is not helping, or the pain interferes with daily function, referral should to a pain specialist should be considered.
  • If the primary care provider begins to feel uncomfortable continuing the current treatment with the chronic pain patient, referral is indicated. A primary care provider should never be compelled to provide treatments beyond his or her level of training or expertise.
  • A positive urine drug screen for abusable medications and/or clear evidence of misuse or abuse requires a frank, honest discussion with the patient which often means tapering treatment medications. An addiction specialist, rather than a pain specialist, is often a more appropriate consultation.

Reference:
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(1):1–49.

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The members of the American Academy of Pain Medicine Primary Care Shared Interest Group are pleased to share these observations and recommendations in the interest of ensuring better patient care.

December 1, 2016

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